NCM103C Reyes, Francesca Ellise G.

Cues Subjective: >no more pain on the lacerated wound Objective: >with lacerated wound on chin secondary to fall >with dresses on chin >dry, intact Measureme nt: Vital Signs: Temp: 36.9 PR: 106 RR: 26 BP: 90/60 Input: Oral: 404ml Output: Urine: 200ml Nursing Diagnosis Impaired Skin Integrity related to lacerated chin manifested by disruption of skin surface and destruction of body structures. Analysis At risk for skin being adversely altered (Nurses Pocket GuideDiagnoses, Prioritized Interventions, and Rationales by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr p.619) Planning Goals: After 8 hour of nursing interventions, the parent/guardian of the client will be able to gain knowledge regarding behaviors/techniques to prevent further skin breakdown. Objectives: After nursing interventions, the parent/guardian of the client will be able to: Intervention Rationale

BSN220/Group 80 Evaluation The parent/guardian of the client was able to gain knowledge regarding behaviors/techniques on preventing further skin breakdown.

To maintain optimal

skin integrity of the client

Perform routine skin inspections, assessing color, temperature, surface changes, texture, and contours. Evaluate color changes in areas of least pigmentation Handle client gently

Systematic inspection can identify developing problems; also promotes early intervention, thus reducing likelihood of progression to skin breakdown Epidermis of infants and very young children is thin and lacks subcutaneous depth that will develop with age. Skin of the older client is also thin, less elastic, and prone to injury, such as bruising and skin tears

The parent/guardian of the client was able to maintain optimal skin integrity of the client.

Practice and instruct client/caregiver(s) in scrupulous hand washing and clean or

sterile technique, as appropriate Maintain/instruct in good skin hygiene

To reduce incidence of contamination or infection

Provide preventative skin care to incontinent client Use paper tape or a nonadherent dressing on frail skin and remove it gently Apply hot and cold applications judiciously

To reduce risk of dermal trauma, improve circulation, and promote comfort. To contact irritants To limit injury minimize with

dermal

Keep nails cut short, encouraging client to refrain from scratching or suggest use of/obtain order for mittens Discuss importance of skin and measures to maintain proper skin functioning.

To reduce risk of dermal injury in persons with circulatory and neurosensory impairments. To prevent dermal injury from scratching. The parent/guardian of the client was able to

To promote wellness to the client

Stress importance of regular inspection/monitoring of skin for changes and effective skin care in preventing skin

The integumentary system is the largest multifunctional organ of the body and thus merits special care.

problems. Avoid products containing perfumes, dyes, preservatives or alcohol, povidoneiodine, hydrogen peroxide. Instruct in care of skin/extremities during cold or hot weather Early detection and reporting to healthcare providers promotes timely evaluation and intervention. May cause dermatitis reactions, may hinder healing To reduce risk of tissue damage, especially in clients with impaired sensation. To promote skin health/healing and to maintain general good health. To reduce/replenish transepidermal water loss. (Nurses Pocket GuideDiagnoses, Prioritized Interventions, and Rationales by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr p.620-623)

Discuss need for adequate nutritional intake

Determine fluid needs/sources for hydration